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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880584
Report Date: 02/01/2023
Date Signed: 02/01/2023 09:55:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220908142507
FACILITY NAME:NAVIN CAREFACILITY NUMBER:
361880584
ADMINISTRATOR:MARTIN, USHAFACILITY TYPE:
735
ADDRESS:12631 ALGONQUIN RDTELEPHONE:
(760) 240-5161
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:5CENSUS: 0DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Usha MartinTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility refused to pick resident up from school.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegations. LPA met with Licensee Usha Martin and explained the purpose of the visit.

The investigation consisted of interviews with the reporting party (RP) and staff members and reviewed facility file documents pertinent to the investigation. The investigation revealed the following. The allegation alleges that at 2:15 p.m., on an unknown date, school staff began loading students on the bus to be transported home. Resident # 1 (R1) refused to get on the bus and stated they wanted to go home and not return to the adult residential facility (ARF) where R1 resided. After several attempts to get R1 on the bus. The school bus left without R1. At 2:45 p.m., the RP contacted the facility where R1 resided. The RP spoke with the Licensee and explained that R1 refused to ride the bus back home. The RP asked the Licensee to pick up R1 from the school. The Licensee refused stating there was not enough staff working at the facility. School staff was eventually able to calm down R1, and two (2) school staff members transported R1 back to the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20220908142507
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NAVIN CARE
FACILITY NUMBER: 361880584
VISIT DATE: 02/01/2023
NARRATIVE
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LPA’s facility file review of the facility’s program design revealed the following: “Navin Care will provide transportation to medical and dental appointments, to destination in the community for the purposes of community integration, day/ work programs and for other purposes, as needed, unless otherwise states in the individual program plan (IPP)”. LPA review of R1’s admission agreement states, “transportation: facility will provide transportation at no additional cost: 2. To all social, recreation and other daily living activities”.

Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20220908142507
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NAVIN CARE
FACILITY NUMBER: 361880584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
80072(a)(2)
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80072 (a)(2) Personal Rights
(2) To be accorded safe, healthful, and comfortable accommodations...

This requirement was not met as evidenced by:
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Licensee shall read CCR section 80072(a)(2) and submit a letter of understanding to the Regional Office (RO) on the POC due date.
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Based on file reviews & interviews, the licensee did not ensure R1 was picked up from school, which poses an potential health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220908142507

FACILITY NAME:NAVIN CAREFACILITY NUMBER:
361880584
ADMINISTRATOR:MARTIN, USHAFACILITY TYPE:
735
ADDRESS:12631 ALGONQUIN RDTELEPHONE:
(760) 240-5161
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:5CENSUS: 0DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Usha MartinTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility did not provide an updated medication list to resident's school.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegations. LPA met with Usha Martin and explained the purpose of the visit.
.
The investigation consisted of interviews with the reporting party (RP) and staff members and reviewed facility file documents pertinent to the investigation. The investigation revealed the following. The allegation alleges that the reporting party (RP) had a conversation with the Licensee about whether changes had occurred in resident #1(R1) medications because of increased behaviors. The RP states that the Licensee said that R1 medications had changed, and the RP requested an updated medication list.

LPA interview with the RP revealed that the request for an updated medication list is a school policy outlined in the student intake packet. The RP states that the school was not administering medication to R1 per a physician's note.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20220908142507
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NAVIN CARE
FACILITY NUMBER: 361880584
VISIT DATE: 02/01/2023
NARRATIVE
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The school that R1 attends is not licensed by the Community Care Licensing Division (CCLD); therefore, it is not a requirement of this agency that the Licensee provides the school with an updated list of R1’s medication.

Based on evidence obtained during the investigation, LPA has determined that the above allegation is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5